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Telemedicine, webside manner, and barriers to care

Telehealth and telemedicine have been gaining in popularity for a number of years, and medical providers’ ability to be effective in these very 21st-century roles has truly become a new expectation of practice.

In this time of the COVID-19 pandemic, the need for positive patient outcomes vis-à-vis telemedicine has never been so important, or so crucially put to the test. And when social and economic disparities loom large in terms of telemedicine reaching those most in need, we can experience a perfect storm of telehealth’s promises remaining largely unfulfilled.

Your Provider is Calling

When patients need medical counsel or symptom management during a situation like the novel coronavirus currently encircling the globe, the ability to provide such care over the phone or computer is paramount. In an effort to expose as few patients to potential infection as possible, telemedicine can mitigate risk while still accomplishing the goals of care.

While telehealth has been practiced in certain quarters for some time, it does appear that the Age of Telemedicine has indeed arrived. Smartphones and tablets are facilitating virtual visits between providers and patients, and a great deal can be accomplished when telemedicine is done well. But what challenges can stand in the way of success?

Providers Challenged by Telehealth

One particular challenge in telehealth is providers’ relative lack of training in conducting assessments, patient interviews, and therapeutic conversations that do not occur in person. Tuning into tone of voice, body language, and other aspects of patient visits can be less than optimal over phone or video, yet these cannot remain barriers when both patient health and provider liability are at stake.

In the age of COVID-19, patients are frequently frightened, confused, and often misinformed. Like people the world over, they may also be living with economic uncertainty, social isolation, and perhaps existential issues such as sick or dying loved ones, food insecurity, inability to access needed medications or treatments, or the threat of eviction or utility shut-offs.

In such dire circumstances, a physician, nurse practitioner, or other provider must have the means to dive deeper, perhaps providing supportive counseling, access to psychosocial and community resources, and taking the time for an empathic and reflective conversation. This can be a stretch for those unschooled in such conversations and may even pose challenges for those trained in mental health.

Yet another challenge is correctly assessing a patient’s physical status or symptoms via phone or video. Can edema or rales be properly identified over the phone? Can a patient’s report be trusted as altogether accurate? These are ongoing troubling questions.

Disparities Rear Their Ugly Head

It is all well and good when a relatively affluent patient accesses telehealth via a smart phone, tablet, or laptop. Such encounters are also more efficient and effective when patients have high-speed cable internet or reliable Wi-Fi.

For economically struggling communities in the inner city, suburbia, or rural areas, high-speed internet or Wi-Fi may simply be wishful thinking. For many patients, a tablet or smartphone may be completely out of reach, with many using basic “flip phones” of days gone by.

These types of economic and technological disparities pose even more insidious barriers to the delivery of effective telehealth visits, and the old nemesis of the “digital divide” rears its ugly head yet again when at-risk patients cannot receive care they clearly need.

Providers are hard-pressed to reach patients who lack adequate cellular service. And when a patient who cannot be assessed by video needs to be seen in person but lacks money for gas or will not come to the clinic for fear of infection with COVID-19, yet more barriers impede proper care.

Healthcare disparities are by nature borne by the poor, and consequently exacerbated by lack of access to the technologies that could benefit such at-risk communities. Herein lies a vexing conundrum of the 21st century.

Solutions Can Be Found

Webside manner and telehealth skill training should now be de rigeur in the education of all healthcare professionals. There is some promise in such training being integrated into medical education, and more will likely be coming online as COVID-19 continues to draw attention to such needs.

The art of listening, skills in motivational interviewing, and training in the development of empathy and compassion are not rocket science; perhaps one solution might be the consolidation of such training for mental health, medical, and nursing students through integrated curricula.

For underserved communities in both rural and urban environments, solutions must be found to mitigate technological barriers. In some cities, libraries and schools provide 24-hour high-speed public Wi-Fi that families and individuals can access from parking lots.

Meanwhile, in some localities, school buses are outfitted to serve as mobile Wi-Fi hotspots that can reach low-income communities so that students can participate in online learning, and, by default, parents may also access the internet for purposes such as telehealth. And if children from underserved communities could be outfitted with tablets or laptops and portable Wi-Fi devices, entire families would benefit in this manner, as well.

Some solutions may simply be tech band-aids, yet we must begin somewhere. If tech companies, healthcare institutions, government, philanthropic and grass-roots organizations, and schools training various healthcare professionals would coordinate efforts, many gains could be made.

In order to optimize the delivery of telehealth services, we need political will, public-private partnerships, and the societal desire to address disparities while shoring up the education and training of professionals who provide such services. With a more holistic approach to the maximization of telemedicine delivery and effectiveness, more patients will receive appropriate and safe care and providers will be more well-trained to meet those patients where they most need to be met.

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About the Author

Keith Carlson, RN, BSN, NC-BC, has been a nurse since 1996. He is the blogger behind the award-winning blog, Digital Doorway, a widely read freelance nurse writer, and motivational/keynote speaker. Keith is the host of The Nurse Keith Show, a popular nursing career podcast. Under the auspices of Nurse Keith Coaching, Keith's passion is helping nurses and healthcare professionals create ultimate satisfaction in both their personal and professional lives.